Search PubMed⌕ Search

Biomedical subjects

W Klepetko

Publications and source records attributed to W Klepetko.

At least 55 records · Page 3Linked to original sources
PubMed1999

Initial experience with two sequential anterolateral thoracotomies for bilateral lung transplantation.

BACKGROUND: Bilateral transsternal thoracotomy (clamshell incision) is the standard approach used for bilateral sequential lung transplantation (BLTX). The morbidity of this large incision can be considerable. Two separate sequential anterolateral thoracotomies represent a less invasive approach. METHODS: The value of this approach was investigated in a prospective series of 13 consecutive patients with the underlying diagnosis of COPD or cystic fibrosis (group A). Results were compared to 8 consecutive patients with similar indications who had undergone BLTX via clamshell incision during the last year prior to this new technique (group B). RESULTS: No intraoperative complications occurred in either group. The difference between the cold ischemic time of the 1st and 2nd transplanted lung was comparable between the 2 groups (81 min+/-17 min in group A vs 79 min+/-14 min in group B, p = 0.783). Postoperative restriction was significantly less in the group operated through 2 separate thoracotomies, as proven by the vital capacity in the first spirometry performed during the 3rd postoperative week (VC group A 55%+/-16% predicted vs 41%+/-11% predicted in group B; p = 0.043). CONCLUSION: The bilateral sequential anterolateral thoracotomy represents a safe and less invasive approach for BLTX in patients with large chest volumes. It minimizes the operative trauma, improves postoperative functional recovery and prevents the potential spread of unilateral complications to the other pleural cavity.

Adult↗
PubMed1999

Independent prognostic role of p16 expression in lung cancer.

OBJECTIVES: The cyclin-dependent kinase p16 (also known as Ink4A, Mts1, Cdkn2, and Cdkn4i) has been proposed as a tumor suppressor gene mapped on chromosome segment 9p21. This study evaluated p16 protein expression in 135 lung cancer specimens and investigated potential genetic alterations occurring in this gene. RESULTS: We found altered p16 immunohistochemical expression to be a frequent event in lung cancer and to be independent of either the histologic type or any other clinical-pathologic feature. Western blot analyses performed on about one third of the specimens correlated highly with these results. In addition, we found p16 immunohistochemical expression to be a favorable prognostic factor in lung cancer in that its reduction or loss correlated with a worse outcome for the patients. Polymerase chain reaction amplification and direct sequencing of p16 exons 1 and 2 revealed no mutations, indicating that p16-altered expression in lung cancer is not necessarily linked to mutational events of these genes. CONCLUSIONS: We conclude that p16-altered expression is both an independent and frequent event in lung cancer and may have an important role in tumorigenesis and in malignant progression of a significant proportion of these cancers. However, the actual incidence and relevance of p16 mutations in this neoplasm continues to be debated, and its analysis seems inconclusive. Our results suggest a prognostic role for the immunodetection of this protein on formalin-fixed and paraffin-embedded specimens. They further suggest its routine use in the evaluation of the frequently unpredictable behavior of lung cancer.

Adenocarcinoma↗
PubMed1999

Bilateral lung transplantation via two sequential anterolateral thoracotomies.

OBJECTIVE: Bilateral anterior trans-sternal thoracotomy (clam shell incision) is the standard approach used for bilateral sequential lung transplantation (BLTX). The morbidity of this large incision can be considerable. Two separate sequential anterolateral thoractomies represent a less invasive approach. METHODS: The value of this approach was investigated in a prospective series of 22 consecutive patients who received BLTX between June 1997 and July 1998. Their underlying diseases were COPD (n = 16), cystic fibrosis (n = 4) and other (n = 2). All patients underwent BLTX through two anterolateral thoracotomies, without the use of cardiopulmonary bypass. The anterior mediastinum and the sternum with all the surrounding tissue were left completely intact. Twenty-one patients underwent spirometrical examination during the postoperative in-hospital stay. Follow-up is 7+/-4 months (range: 3 to 15). RESULTS: The only intraoperative complication was severe reperfusion edema of the first transplanted lung seen in one patient at the end of the operation, which required pneumonectomy during the same session. All other operations were uneventful. The difference between the cold ischemic time of the first and second transplanted lung was 83+/-17 min. Median intubation duration, ICU- and in-hospital-stay were 1.5, 5 and 20 days, respectively (ranges: 1 to 96, 2 to 96 and 15 to 96, respectively). One major perioperative complication occurred and was due to gross donor/recipient size mismatch: the patient required lobectomy of the consolidated right upper lobe 11 days after transplantation. In 19 patients (86.4%), this less extensive incision allowed early postoperative mobilization, which resulted in good ventilatory performance, with VC of 53+/-15 and FEV1 of 60+/-20% of the predicted, respectively, at the first spirometry, 3 weeks after the operation. Three months survival was 100%. CONCLUSION: The bilateral sequential anterolateral thoracotomy represents a safe and minimal invasive approach for BLTX compared with the clam shell incision. It minimizes the operative trauma, improves postoperative functional recovery and prevents the potential spread of unilateral complications to the other pleural cavity.

Adolescent↗
PubMed1999

Impact of different coverage techniques on incidence of postpneumonectomy stump fistula.

OBJECTIVE: Postpneumonectomy bronchial stump fistula (PBSF) is a serious complication with a reported incidence between 0 and 12%. The aim of this retrospective study was to investigate the effectiveness of different coverage techniques of the bronchial stump applied in a consecutive series of pneumonectomies in avoiding this particular problem. METHODS: Between 1/87 and 10/97, 129 patients (90 male, 39 female, mean age 57.8 years, range: 15-78 years) underwent pneumonectomy by one surgeon (W.K.). In 14 patients, additional resection procedures were performed (aorta n = 6, vena cava n = 5, thoracic wall n = 3). In all patients with malignancies (n = 123), mediastinal lymphadenectomy was routinely added to the procedure. Bronchial stump closure was performed by means of stapling devices in all patients. Coverage of the bronchial stump was performed with a generous pedicled pericardial flap and concomitant reconstruction of the pericardium with Vicryl mesh (n = 50), with a portion of the posterior pericardium (n = 16), with the azygos vein (n = 12), with surrounding mediastinal tissue (n = 25), with pleura (n = 16), or with intercostal muscle flap (n = 3); no coverage at all was performed in seven patients. In all patients with high risk for development of PBSF, i.e. patients who received any form of neoadjuvant therapy or had extended resections, the pericardial flap technique was used. RESULTS: Perioperative mortality was 5.4% (n = 7) and five patients (3.9%) experienced significant perioperative complications, with one of them directly related to the method of bronchial stump coverage (cardiac tamponade due to the use of a too small Vicryl mesh for reconstruction of the pericardium). Follow-up was 96.1% complete (five patients were lost to follow-up). Fourty-seven patients (36.4%) died late after operation (mean 19+/-13 months, median 17 months), mainly due to recurrence of their underlying malignant disease. PBSF occurred in one patient only (0.8%), 2 weeks after operation (coverage with pleura). No PBSF was seen in the long term follow-up period. CONCLUSION: Coverage of the bronchial stump contributes to a low incidence of PBSF. In view of the fact, that this serious complication was completely avoided in the pericardial flap group (used in patients with expected higher risk for PBSF), this particular technique seems to offer the best results.

Adolescent↗
PubMed1999

Transient left ventricular failure following bilateral lung transplantation for pulmonary hypertension.

BACKGROUND: Bilateral lung transplantation is an established therapy for end-stage pulmonary hypertension. Its early postoperative outcome may be biased by various complications resulting in unexpected deterioration of the patient in terms of hemodynamics and blood gases. METHODS: We have reviewed the early postoperative course of patients who underwent bilateral lung transplantation for pulmonary hypertension at our institution and analyzed all available data, especially hemodynamic measurements, echocardiographic documentation and therapeutical strategies, in those cases where cardiac dysfunction was found to be responsible for clinical deterioration. RESULTS: Three out of 20 lung transplant recipients operated for pulmonary hypertension experienced severe respiratory insufficiency accompanied by hemodynamic decompensation during the first days after surgery. Clinical and laboratory findings together with results of echocardiography and pulmonary artery catheterism helped establish the diagnosis of left ventricular failure. This proved to be transitory, but the response to therapy (inotropic drugs, afterload reduction and eventually prostaglandins) was very variable. Adequately treated, this complication did not preclude the outcome of transplantation by itself. CONCLUSION: Left ventricular failure is a possible complication after lung transplantation for pulmonary hypertension. Echocardiography and pulmonary artery catheterism may be useful adjuvant diagnostic tools, beside routine physical examination, chest X-ray, and laboratory analysis. Therapy of this complication must be adapted individually and may be complex.

Adult↗
PubMed1999

Comparison between mycophenolate mofetil- and azathioprine-based immunosuppressions in clinical lung transplantation.

BACKGROUND: The aim of the study was to assess the impact of mycophenolate mofetil (MMF) on the early phase after lung transplantation. PATIENTS AND METHODS: Thirty-eight consecutive patients between November 1994 and January 1997 were treated with cyclosporine, prednisolone, antithymocyte globuline induction therapy, and either MMF (n = 21) or azathioprine (Aza) (n = 17). Four patients from the MMF group and 2 patients from the Aza group were intubated and in the ICU prior to transplantation. Demographic data and primary diagnosis were comparable. MMF was administered at a dosage of 2 gm/day whereas Aza was initiated at 2 mg/kg/day and adapted by leukocyte count. Three-month survival and incidence of rejections and infections were compared. RESULTS: Six-month survival in the MMF group was 76% compared to 65% in the Aza group (n.s.). The mean number of acute rejection episodes in the MMF and Aza group were 0.29+/-0.10 and 1.53+/-0.29 (p<0.01) respectively. Transbronchial biopsy (TBB) results > or =grade 2 ISHLT were seen in 10% of MMF and in 43% of Aza-treated patients; completely free from rejection were 17 MMF and 3 Aza patients. The mean number of infections per patient in the MMF and Aza group were 1.57+/-0.29 and 2.29+/-0.40 respectively, bacterial (1.10 vs. 1.71), viral (0.35 vs. 0.33), and fungal (0.14 vs. 0.24) infections were the same in both groups. CONCLUSIONS: These data result suggest that mycophenolate mofetil therapy is more effective in preventing rejection episodes in patients early after lung transplantation than therapy with azathioprine. We therefore conclude that MMF is a safe and effective drug to optimize immunosuppressive therapy in the early phase after lung transplantation.

Adolescent↗
PubMed1999

Surgical aspects and techniques of lung volume reduction surgery for severe emphysema.

Lung volume reduction surgery (LVRS) has become an accepted procedure for palliative treatment of diffuse, nonbullous emphysema. Single or multiple peripheral segmental wedge resections of the most destroyed areas of the lungs are performed with the use of stapling devices, in order to decrease hyperinflation and restore diaphragmatic function. Median sternotomy, videoendoscopy or anterior muscle sparing thoracotomies have been used as surgical approaches. The functional improvement after bilateral resections exceed those after a unilateral approach. LVRS has demonstrated its potential as an alternative to transplantation, and with growing experience, the indications for the procedure have been widened. In selected patients with peripheral lung cancer who have been considered unsuitable for a surgical resection, the combination of both tumour resection and LVRS has successfully been performed. In contrast to LVRS, laser surgery of the emphysematous lung has been abandoned in most institutions.

Contraindications↗
PubMed1999

Post-transplant acute myeloid leukemia (PT-AML).

Acute myeloid leukemia following organ transplantation (PT-AML) is a rare event with only a few published cases in the literature. We present three patients who developed AML (FAB M1, M5, M4) after renal, double lung or liver transplantation. Molecular analysis detected a t(9;11) in one patient and documented the recipient origin of AML in a second patient. All patients were treated with chemotherapy. Immunosuppression was reduced to cyclosporin A (CsA) and prednisone in two patients and to prednisone alone in one patient. Two patients achieved a complete remission (CR), with a remission duration of 4.6 months in one patient, the other patient died from septicemia after 15.2 months in CR. One patient was refractory to chemotherapy and died from septicemia. This report together with the documented cases in the literature suggests that PT-AML (1) develops after a median interval of 5 years after transplantation with variable latency (range, <1-17 years); (2) is heterogeneous with respect to FAB classification; (3) shows chromosomal and molecular changes typical of therapy-related AML (t-AML: -7, +8, 11q23, inv16, t(15;17)); (4) standard chemotherapy is feasible after reduction of immunosuppression and produces a CR rate of 56% with a median remission duration of 4.6 months and an overall survival of 2.6 months; (5) the major complications are early death (25%), gram-negative septicemia, progressive disease or relapse. This review provides diagnostic and therapeutic experiences and guidelines for the management of this increasing group of post-transplant patients.

Acute Disease↗
PubMed1999

Lung volume reduction surgery: preoperative functional predictors for postoperative outcome.

UNLABELLED: Approximately 20% of patients undergoing lung volume reduction surgery (LVRS) exhibit no functional improvement postoperatively. Therefore, we examined whether variables characterizing ventilatory mechanics before LVRS could serve as predictors for outcome. In 32 patients undergoing LVRS, lung function, dyspnea score, and ventilatory mechanics were assessed preoperatively and 3 mo after LVRS. Ventilatory mechanics were characterized by total resistive work of breathing (WOB), mean airway resistance (Rawm), and dynamic intrinsic positive end-expiratory pressure (PEEPi,dyn). Calculations of WOB, Rawm, and PEEPi,dyn were made from measurements of airflow, volume, and esophageal pressure. Preoperative PEEPi,dyn correlated well with the increase in forced expiratory volume percent predicted (r = 0.75; P < 0.0001) and the decrease in dyspnea score (r = -0.74; P < 0.0001) after LVRS. Rawm and WOB showed inferior correlation compared with PEEPi,dyn. The examination of distinct threshold values for WOB, Rawm, and PEEPi,dyn with respect to predicting improvement resulted in a sensitivity of 93% and specificity of 88% for a cutoff point of preoperative PEEPi,dyn > or =5 cm H2O. Preoperative PEEPi,dyn correlated well with improvement in forced expiratory volume and dyspnea score after LVRS. Thus, preoperative assessment of PEEPi,dyn could improve risk to benefit stratification before LVRS. IMPLICATIONS: We examined the preoperative ventilatory mechanics of patients with emphysema undergoing lung volume reduction surgery with respect to their value in predicting outcome. Preoperative intrinsic positive end-expiratory pressure correlated well with the increase in forced expiratory volume in 1 s after surgery. Thus, this variable seems promising for improved patient selection.

Adult↗
PubMed1999

Neural drive to the diaphragm after lung volume reduction surgery.

STUDY OBJECTIVES: The aim of this study was to investigate prospectively the changes in neural drive to the diaphragm in the first year after lung volume reduction surgery (LVRS) in patients with COPD. PATIENTS AND METHODS: In 14 patients with severe emphysema (mean +/- SD; age, 53.7 +/- 8.3 years; FEV(1), 0.64 +/- 0. 18 L; residual volume [RV], 5.33 +/- 1.25 L; PaO(2), 62.3 +/- 9.0 mm Hg; PaCO(2), 39.0 +/- 6.0 mm Hg), we assessed lung function, arterial blood gases, maximal exercise capacity (Wmax), and oxygen uptake (f1.gif" BORDER="0">O(2)max); intrinsic positive end-expiratory pressure (PEEPi); diaphragmatic strength (transdiaphragmatic pressure, Pdisniff) and endurance capacity (tlim); central diaphragmatic drive assessed by root mean square analysis of the esophageal electromyogram (rmsdia); and isotime dyspnea during loaded breathing tests (BS). RESULTS: Despite a significant increase (expressed as a percentage of baseline) in FEV(1) (40.6%) and a decrease in RV (30.0%) and PEEPi (75.7%) 1 month after LVRS, the improvements in Wmax (31.2%) and f1.gif" BORDER="0">O(2)max (13.7%); Pdisniff (25.4%) and tlim (64.9%); rmsdia (34.6%); and BS (21.7%) did not reach statistical significance (p < 0.05) until 6 months after LVRS. Arterial blood gases did not change significantly. Significant correlations were found between decrease in rmsdia and changes in PEEPi (r = 0.69), Wmax (r = -0.56), Pdisniff (r = -0.65), tlim (r = -0.59), and BS (r = 0.71) 6 months after LVRS. CONCLUSIONS: Our results show that LVRS is able to increase the efficacy of the respiratory pump and by this way reduce ventilatory drive and respiratory effort sensation.

Diaphragm↗
PubMed1998

[Protein catabolism after lung transplantation and heart transplantation].

Any surgical intervention is associated with an activation of protein catabolism, the extent of which is dependent on the severity of surgical trauma. There is a paucity of reports on protein catabolism after transplantation of chest organs (lung transplantation (LTX) and heart transplantation (HTX)). The aim of the present study was to quantify and compare the extent of postoperative protein catabolism and associated metabolic perturbations in patients after LTX and HTX. Eighteen consecutive patients after LTX and 15 consecutive patients after HTX who required postoperative intensive care for more than 4 days, constituted the study population. The nitrogen balance (assessed on the basis of the urea nitrogen production rate and nitrogen intake) was assessed retrospectively and correlated with insulin requirements, immunosuppression and the clinical course. Within the first 5 days the nitrogen balance became progressively negative in both groups, reaching a maximum on the 5th day. Thereafter the nitrogen balance of patients following LTX remained negative, whereas the nitrogen balance of patients following HTX tended to improve. The evolution of nitrogen balance significantly differed between both groups (p < 0.01). The mean nitrogen loss was -0.29 +/- 0.17g/kg BW/day after LTX versus -0.22 +/- 0.12g/kg BW/day after HTX. Smaller amounts of glucocorticoids were used for immunosuppression in patients after HTX than in patients after LTX; nevertheless, heart transplant recipients required higher doses of insulin to maintain normoglycemia. A regression analysis revealed that the duration of stay at the intensive care unit (p < 0.001) and the amount of glucocorticoids (p < 0.01) negatively affected the nitrogen balance, whereas an increased protein intake (p < 0.001) exerted a positive effect. Compared to other major surgical procedures, protein catabolism is excessively elevated in patients after thoracic transplantation. Immunosuppressive therapy with glucocorticoids contributes to protein degradation; the nitrogen balance after LTX is more negative than that after HTX because of higher glucocorticoid requirements following LTX. More aggressive nutritional intervention and especially an increased nitrogen intake might help to reduce protein losses in these patients.

Adult↗
PubMed1998

Metal ion-induced toxic histamine release from human basophils and mast cells.

Recent data suggest that distinct metal ions can be released from dental alloys or other biomaterials, and may cause toxic effects on various cells. In this study, the effects of 14 metal ions on histamine release from human blood basophils (n = 4), isolated tissue mast cells (lung n = 8, uterus n = 2, skin n = 1, gingiva n = 1), the basophil cell line KU-812, and the mast cell line HMC-1 were analyzed. Of the 14 metal ions, Ag+ (0.33 mM) and Hg2+ (0.33 mM) were found to induce release of histamine in blood basophils, KU-812, mast cells, and HMC-1. The effects of Ag+ and Hg2+ were dose dependent and were observed within 60 min of incubation. In primary mast cells and basophils, AU3+ (0.33 mM) also induced histamine release, whereas no effects of Au3+ on HMC-1 or KU-812 cells were seen. The other metal ions showed no effects on primary or immortal cells within 60 min. However, Pt4+ (0.33 mM) induced histamine liberation in HMC-1 and lung mast cells after 12 h. The Ag+- and Hg2+-induced rapid release of histamine from HMC-1 was associated with ultrastructural signs of necrosis, but not apoptosis. In contrast, prolonged exposure to Pt4+ (0.33 mM, 14 h) induced apoptotic cell death in HMC-1 cells, as assessed by electron microscopy and DNA analysis. Together, certain metal ions induce distinct cytopathogenic effects in mast cells and basophils. Whereas Ag+, Hg2+, and Au3+ cause direct toxicity, Pt4 causes cell death through induction of apoptosis. Whether such effects contribute to local adverse reactions to metal-containing biomaterials in vivo remains to be determined.

Basophils↗
PubMed1998

[Functional results and long-term outcome after bilateral lung transplantation for pulmonary hypertension].

Pulmonary hypertension (PH) signifies elevated blood pressure in the pulmonary circulation either due to clearly defined causes (cardiac, pulmonary-parenchymatous, systemic) or of idiopathic origin (primary PH, PPH). While conservative treatment is beneficial only for a small number of patients, lung transplantation represents a curative measure. The optimal form of transplantation [i.e. single lung (SLTX), bilateral lung (BLTX) or combined heart-lung transplantation (HLTX)] is still under discussion. This study is a retrospective analysis of 16 patients with different forms of PH who underwent BLTX from 1992 to 1996 in Vienna. Four patients had Eisenmenger's disease due to atrial septum defect, 3 had chronic thromboembolic PH and 9 had PPH. BLTX with cardiopulmonary bypass was the standard procedure in all patients. Acute retransplantation had to be performed in 3 patients. Mean pulmonary arterial pressure was reduced from 63 +/- 11 mmHg preoperatively to 23 +/- 5 mmHg on the second day postoperatively (p < 0.0001), while the cardiac index concomitantly improved from 2.1 +/- 0.5 to 3.9 +/- 1.2 l/min/m2 (p < 0.05). Echocardiography proved normalisation of right ventricular wall thickness and end-diastolic diameter within 12 months, while tricuspid insufficiency, present in all patients before transplantation, resolved completely. Perioperatively 4 patients (25%) died due to septic complications (n = 3) or therapy refractory rejection (n = 1). Follow-up of the remaining patients ranged from 6 to 51 months (mean 33 +/- 17). One patient died at 8 months due to fungal sepsis. Eleven patients (68%) are currently alive. Only 2 of them show functional signs of chronic allograft rejection (bronchiolitis obliterans syndrome). All patients are at present in NYHA functional class I or II. In conclusion, BLTX results in complete recovery of right ventricular function and morphology and offers good functional long-term results. Because SLTX correlates with a high incidence of reperfusion edema, and HLTX is seriously limited by the scarcity of donor organs, BLTX should be the method of choice for treating end stage PH.

Adult↗
PubMed1998

Pulmonary retransplantation: predictors of graft function and survival in 230 patients. Pulmonary Retransplant Registry.

BACKGROUND: Despite improving results in lung transplantation, a significant number of grafts fail early or late postoperatively. The pulmonary retransplant registry was founded in 1991 to determine the predictors of outcome after retransplantation. We hypothesized that ambulatory status of the recipient and center retransplant volume, which had been previously shown to predict survival after retransplantation, would also be associated with improved graft function postoperatively. METHODS: Two hundred thirty patients underwent retransplantation in 47 centers from 1985 to 1996. Logistic regression methods were used to determine variables associated with, and predictive of, survival and lung function after retransplantation. RESULTS: Kaplan-Meier survival was 47% +/- 3%, 40% +/- 3%, and 33% +/- 4% at 1, 2, and 3 years, respectively. On multivariable analysis, the predictors of survival included ambulatory status or lack of ventilator support preoperatively (p = 0.005; odds ratio, 1.62; 95% confidence interval, 1.15 to 2.27), followed by retransplantation after 1991 (p = 0.048; odds ratio, 1.41; 95% confidence interval, 1.003 to 1.99). Ambulatory, nonventilated patients undergoing retransplantation after 1991 had a 1-year survival of 64% +/- 5% versus 33% +/- 4% for nonambulatory, ventilated recipients. Eighty-one percent, 70%, 62%, and 56% of survivors were free of bronchiolitis obliterans syndrome at 1, 2, 3, and 4 years after retransplantation, respectively. Factors associated with freedom from stage 3 (severe) bronchiolitis obliterans syndrome at 2 years after retransplantation included an interval between transplants greater than 2 years (p = 0.01), the lack of ventilatory support before retransplantation (p = 0.03), increasing retransplant experience within each center (fifth and higher retransplant patient, p = 0.04), and total center volume of five or more retransplant operations (p = 0.05). CONCLUSIONS: Nonambulatory, ventilated patients should not be considered for retransplantation with the same priority as other candidates. The best intermediate-term functional results occurred in more experienced centers, in nonventilated patients, and in patients undergoing retransplantation more than 2 years after their first transplant. In view of the scarcity of lung donors, patient selection for retransplantation should remain strict and should be guided by the outcome data reviewed in this article.

Adolescent↗
PubMed1998

Morphologic grading of the emphysematous lung and its relation to improvement after lung volume reduction surgery.

BACKGROUND: The morphologic criteria for lung volume reduction surgery, such as severity and heterogeneity of disease, differ widely between patients, and this makes any comparison of functional results between centers difficult. Here we present a morphologic scoring system and describe its possible relation to functional results after lung volume reduction operations. METHODS: Between September 1994 and December 1996, 47 consecutive patients underwent bilateral lung volume reduction operations. The morphology of emphysema was quantified with standard chest roentgenograms and computed tomographic imaging, which were used to define the following four variables: degree of hyperinflation (grade 0 to 4), degree of impairment in diaphragmatic mechanics, degree of heterogeneity (grade 0 to 4), and severity of parenchymal destruction (range, 0 to 48). RESULTS: All four variables showed good reproducibility. Degree of heterogeneity had a significant influence on functional improvement in terms of forced expiratory volume in 1 second (p = 0.0413, r2 = 0.11). Severity of parenchymal destruction was significantly associated with 30-day mortality: patients who died after operation (n = 4) had a severity of parenchymal destruction of 28.4 +/- 2.1 compared with 21.3 +/- 1.0 for those who survived (n = 43) (p = 0.003). CONCLUSIONS: This morphologic scoring system is easy to use, is reproducible, and allows quantification of the morphology of emphysema, thereby allowing definition of different patient subgroups. Such an exact morphologic quantification may help in the comparison of functional results between centers. Furthermore, the risk factors for certain morphologic subgroups, such as patients with a homogeneous distribution pattern, may be clarified in the future.

Adult↗